Chronic Disease Management (CDM) Plan Notes

Reporting Month/Year: [Enter Month/Year] Patient Information Full Name: [Enter Patient Name] Date of Birth (DOB): [MM/DD/YYYY] Medical Record (MR) #: [Enter MR#] Primary Address: [Enter Patient Address] Contact Number: [Enter Contact Number] Emergency Contact: [Enter Emergency Contact Name, Relationship, and Phone Number] Usual Medical Practitioner: [Enter Practitioner Name, Credentials] Practice Name: [Enter Practice Name] Practice Contact: [Enter Practice Contact Information] Eligibility Criteria - The patient’s chronic or terminal condition: [Describe chronic or terminal condition and confirm eligibility for CDM services.] - Expected duration of condition(s): [Specify if condition is expected to last at least six months or longer.] - Verification of CDM service eligibility: [Confirm eligibility has been checked through HPOS/MBS.] - Usual medical practitioner’s role: [Confirm if the practitioner has provided most care in the last 12 months or will continue to do so for the next 12 months.] Chronic Medical Conditions - [Condition Name] (ICD-10: [Code]) - [Provide a brief description of the diagnosis, including onset, severity, and relevant clinical indicators.] - [Describe the management plan, including medications, lifestyle interventions, and required monitoring.] - [Include details of any referrals to specialists, ongoing monitoring needs, and lab tests required.] - [Condition Name] (ICD-10: [Code]) - [Provide a brief description of the diagnosis, including onset, severity, and relevant clinical indicators.] - [Describe the management plan, including medications, lifestyle interventions, and required monitoring.] - [Include details of any referrals to specialists, ongoing monitoring needs, and lab tests required.] Other Medical Conditions - [Condition Name] – [Provide a brief description of the condition, its impact on the patient’s health, and the management strategy, including medication, lifestyle modifications, and referrals.] - [Condition Name] – [Provide a brief description of the condition, its impact on the patient’s health, and the management strategy, including medication, lifestyle modifications, and referrals.] Patient Assessment and Needs Identification - Functional Status: [Describe the patient’s level of mobility, any limitations due to chronic conditions, and impact on daily activities.] - Cognitive Status: [Assess cognitive function, including memory, comprehension, and need for reminders or assistance with daily tasks.] - Psychosocial Needs: [Evaluate the patient’s support system, emotional well-being, and any concerns related to their condition, including anxiety or depression.] - Nutritional Needs: [Identify any dietary restrictions, challenges with maintaining appropriate nutrition, and referrals to dietitians if needed.] - Medication Management: [Review medication adherence, need for education, polypharmacy risks, and plans for pharmacist review.] - Lifestyle Factors: [Assess smoking history, alcohol intake, physical activity levels, and recommendations for behavior modification if necessary.] CDM Plan Development Planned Interventions and Services - Medical Management: [Outline the plan for monitoring chronic conditions, including frequency of assessments, laboratory tests, and medication adjustments.] - Preventive Care Needs: [Specify completed or pending vaccinations, screenings, and preventive interventions.] - Patient Education: [Provide information on disease self-management, symptom monitoring, and importance of adherence to the treatment plan.] - Referrals to Allied Health Services: - Physiotherapy: [Describe reason for referral and expected outcome.] - Dietetics: [Describe reason for referral and expected outcome.] - Podiatry: [Describe reason for referral and expected outcome.] - Pharmacy Medication Review: [Describe reason for review and any concerns about medication safety or interactions.] Health Goals (Short and Long-Term) - Short-Term Goal 1: [Specify a short-term goal that is achievable within three months.] - Short-Term Goal 2: [Specify another short-term goal relevant to the patient's conditions.] - Long-Term Goal 1: [Specify a long-term goal related to disease management and prevention of complications.] - Long-Term Goal 2: [Specify another long-term goal focusing on improving the patient’s overall well-being.] Monitoring and Support Services Date: [MM/DD/YYYY] - Service Provided: [Describe the type of service provided, such as medication review, symptom management, or health education.] - Duration: [XX minutes] - Provider Name & Credentials: [Enter Provider Name and Credentials] Date: [MM/DD/YYYY] - Service Provided: [Describe the type of service provided, such as medication review, symptom management, or health education.] - Duration: [XX minutes] - Provider Name & Credentials: [Enter Provider Name and Credentials] Date: [MM/DD/YYYY] - Service Provided: [Describe the type of service provided, such as medication review, symptom management, or health education.] - Duration: [XX minutes] - Provider Name & Credentials: [Enter Provider Name and Credentials] Referrals to Allied Health Professionals - GPMP and Team Care Arrangements (TCAs) Status: [Confirm completion of GPMP and TCAs.] - Referral Letter Status: [Confirm if referral letter has been sent to the allied health provider.] - Allied Health Practitioners Engaged: - Dietitian: Appointment scheduled for [Date] - Physiotherapist: Appointment scheduled for [Date] - Podiatrist: Appointment scheduled for [Date] Review and Reassessment - Planned Review Date: [MM/DD/YYYY] - Changes in Patient Condition: [Describe any significant changes in the patient’s condition or confirm no significant changes.] - Plan Modifications: [Specify if modifications are required and detail changes, or confirm no modifications needed.] Billing and Medicare Compliance - CDM Plan Development: [Confirm claim under MBS Item 721.] - Monitoring and Support Services: [Confirm claim under MBS Item 10997 (Enter number of units: [X]).] - Allied Health Referrals: [Confirm claim under MBS Item 723.] - Review Services: [Confirm claim under MBS Item 732.] Signatures Usual Medical Practitioner: [Enter Practitioner Name, Credentials] Date: [MM/DD/YYYY] Practice Nurse/Support Staff Signature: [Enter Name, Credentials] Date: [MM/DD/YYYY] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)